1. Field of the Invention
The present invention relates to the field of methods for the insertion of catheters into the vascular system, and more particularly to the introduction of hyperalimentation feeding catheters and the like into the subclavian vein.
2. Description of the Prior Art
In certain instances it is desirable to have repeated and frequent access to a patient's circulation for the delivery of materials such as oncology chemicals or hyperalimentation fluids. A procedure has been developed in the prior art to avoid the need for repeated venipuncture under such circumstances. This has been accomplished by the use of Hickman or Broviac type indwelling catheters.
Prior to use of the Hickman type indwelling catheter, many patients required arteriovenous shunts that have inherent problems of clotting and infection when used for infusing blood products and antibiotics. It has also been found that it is difficult to maintain nutritional status with the internal shunt, and the infusion of 50 percent dextrose in water is difficult because the blood flow through the shunt is not swift enough to handle such a viscous solution.
The Hickman indwelling right atrial catheter provides ready access to the patient's circulation both for drawing blood and for administering drugs, blood products, and total parenteral nutrition. The catheter can also be used to monitor central venous pressure and to withdraw blood for plasmapheresis. The use of this catheter can also provide added comfort and nutrition to inpatients, and outpatients can be sent home with the catheter in place to allow them the independence of administering their own parenteral nutrition.
The Hickman catheter is a modification of the Broviac catheter which also has been commonly used for total parenteral nutrition. The Hickman catheter has a larger bore with a 1.6 mm inside diameter, compared to the 1.0 mm bore of the Broviac catheter. The Hickman catheter is typically made of polymeric silicone rubber and has one or two Dacron felt cuffs used to anchor it in place subcutaneously. The external end of the catheter is threaded and comes with a male Luer lock cap. An alternate cap which is threaded and has a port through which injections can be adminstered directly may also be used, allowing less chance of contamination and air embolism.
The procedure for the placement of a Hickman catheter is generally as follows. A two inch incision is made in the deltopectoral groove below the acromion of the right clavicle, and the cephalic vein is isolated. A subcutaneous tunnel is formed using long forceps, exiting at an area between the sternum and the nipple. The catheter is pulled through the tunnel, inserted in the cephalic vein, and positioned in the lower right atrium at the entrance to the right atrium. The Dacron cuff is positioned in the subcutaneous tunnel, and the tunnel and the cuff serve as barriers to infection. This method is known in the art, and is further discussed in an article entitled "The Hickman Indwelling Catheter", by Joan Byeletich and R. O. Hickman, American Journal of Nursing, January 1980, pp. 62-65. The method of the present invention is similar, but provides a less traumatic procedure for the insertion of such a catheter.
The method of the present invention utilizes certain devices and materials, some of which are known in the art for use in other procedures. Tunneling devices in the prior art have encompassed a variety of instruments, such as the use of long forceps as previously discussed. Such devices are disadvantageous to the extent that the blunt instruments require a fair amount of disection and blunt trauma to establish the appropriate tunnel between the entrance and exit sites. Catheters for insertion into the vascular system are also well known and do not in themselves form a part of the present invention. For example, the present method may preferably use a permanent pacemaker lead introducer to accomplish the subclavian puncture.
In U.S. Pat. No. 3,946,741, issued to Adair on Mar. 30, 1976, there is described a urethral catheter and body drainage device comprising a telescoping tube assembly. The Adair patent is directed primarily to constructions for sealing the device to prevent leakage from between the tubes, and does not relate to a vascular catheter. A bladder drainage catheter and apparatus is described in U.S. Pat. No. 3,680,562, issued to Wittes et al. on Aug. 1, 1972. The Wittes et al. device includes bifurcated wings to anchor the apparatus to the skin, and also has a removeable piercing element with beveled point which extends beyond the plastic tube for insertion purposes.
A catheter holding device which can be used with the subclavian vein is disclosed in U.S. Pat. No. 4,149,535, issued to Volder on Apr. 17, 1979. The Volder device provides for the measurement of central venous pressure, and includes a side port to accept catheters for other purposes such as transfusion of liquids into the blood vessel. A hollow needle for positioning a catheter in a patient is described in U.S. Pat. No. 3,677,243, issued to Nerz on July 18, 1972. The Nerz needle includes a score line to permit the needle to be torn away for removal from a catheter inserted through it. A catheter having a particular chemical composition is disclosed in U.S. Pat. No. 4,146,033, issued to Ide et al. on Mar. 27, 1979.